BackgroundSubsidizing healthcare costs through insurance schemes is crucial to overcome financial barriers to health care and to avoid high medical expenditures for patients in China. The health insurance could decrease financial risk by less out-of-pocket (OOP) payment, but not promise the protection equity. With the growth of New Cooperative Medical Scheme (NCMS) financing and coverage since 2008, the protection effectiveness and equity of the modified NCMS policies on financial burden should be further evaluated.MethodsA cross-sectional household survey was conducted in Zhejiang, Hubei, and Chongqing provinces by multi-stage stratified random sampling in 2011. A total of 1,525 households covered by the NCMS were analyzed. The protection effectiveness and protection equity of NCMS was analyzed by comparing the changes in health care utilization and medical expenditures, and the changes in the prevalence of catastrophic health expenditure (CHE) and its concentration indices (CIs) between pre- and post-NCMS reimbursement, respectively.ResultsThe medical financial burden was still remarkably high for the low income rural residents in China due to high OOP payment, even after NCMS reimbursement. In Hubei province, the OOP payment of the poorest quintile was almost same as their households’ annual expenditures. Even it was higher than their annual expenditures in Chongqing municipality. Effective reimbursement ratio of both outpatient and inpatient services were far lower than nominal reimbursement ratio originally designed by NCMS plans. After NCMS reimbursement, the prevalence of CHE was considerably high in all three provinces, and the absolute values of CIs were even higher than those before reimbursement, indicating the inequity exaggerated.ConclusionPolicymakers should further modify NCMS policy in rural China. The high OOP payment could be decreased by expanding the drug list and check directory for benefit package of NCMS to minimize the gap between nominal reimbursement ratio and effective reimbursement ratio. And the increase in medical expenditures should be controlled by monitoring excess demand from both medical service providers and patients, and changing fee-for-service payment for providers to a prospective payment system. Service accessibility and affordability for vulnerable rural residents should be protected by modifying regressive financing in NCMS, and by providing extra financial aid and reimbursement from government.

Based on the high prevalence and undiagnosed rate of diabetes mellitus in China in recent years, the aim of this work was to evaluate the availability, price and affordability of pharmacotherapy for diabetes in public hospitals in Hubei province, China. In 2016, a cross-sectional survey was conducted using World Health Organization/Health Action International (WHO/HAI) methodology. Information on the availability and prices of 20 antidiabetic drugs was collected from 34 public hospitals representing three levels of care. Of the 20 antidiabetic drugs, 70.6% were below 50% availability. Total availability of the 20 drugs was higher in secondary and tertiary hospitals than in primary hospitals. All three hospital levels had higher availability of essential than non-essential antidiabetic medicines. The median markup ratios of originator brands (OBs) and lowest-price generics (LPGs) were 15.6% and 2.1%, respectively. The median potential saving ratio of using generics was 31.3%. Overall, the median affordability of 31 antidiabetic drugs ranged from 1.2 to 8.5 days of disposable income for residents with three income levels. After insurance reimbursement, the increase in the proportion of affordable drugs in urban and rural areas averaged 35.5% and 12.9%, respectively. The proportion of drugs with low availability and low affordability dropped from 54.8% to 38.7%. However, 41.7% of urban diabetic patients and 74.0% of rural diabetic patients remained unable to afford the drugs surveyed. Higher income and generic substitution are factors facilitating affordability. In Hubei province, the overall availability of 20 antidiabetic drugs was low, especially in primary hospitals. The affordability of most drugs surveyed was also low. Current health insurance can greatly improve affordability for urban residents with middle or high income. Policy changes should focus on the supply, pricing and clinical use of antidiabetic drugs and special health insurance plan for low income population with diabetes.

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We aimed to elucidate the effect of bilirubin on dyslipidemia and nephropathy in a diabetes mellitus (DM) type I animal model. Sprague-Dawley rats were separated into control, DM, and bilirubin-treated DM (Bil) groups. The Bil group was injected intraperitoneally with 60 mg/kg bilirubin 3 times per week and hepatoma cells were cultured with bilirubin at a concentration of 0.3 mg/dL. The Bil group showed lower serum creatinine levels 5 weeks after diabetes onset. Bilirubin treatment also decreased the amount of mesangial matrix, lowered the expression of renal collagen IV and transforming growth factor (TGF)-β1, and reduced the level of apoptosis in the kidney, compared to the DM group. These changes were accompanied by decreased tissue levels of hydrogen superoxide and NADPH oxidase subunit proteins. Bilirubin decreased serum total cholesterol, high-density lipoprotein cholesterol (HDL-C), free fatty acids, and triglycerides (TGs), as well as the TG content in the liver tissues. Bilirubin suppressed protein expression of LXRα, SREBP-1, SCD-1, and FAS, factors involved in TG synthesis that were elevated in the livers of DM rats and hepatoma cells under high-glucose conditions. In conclusion, bilirubin attenuates renal dysfunction and dyslipidemia in diabetes by suppressing LXRα and SREBP-1 expression and oxidative stress.Graphical Abstract

In order to investigate medical professional attitudes and behaviors in China and explore the influencing factors with a focus on hospital internal management, we developed a 13-item professional attitudes and 11-item behaviors inventory. Self-administered questionnaires were distributed to 390 physicians mainly in four specialties in two tertiary Chinese hospitals in 2011. 306 completed questionnaires were collected. More than 90% of respondents agreed with at least nine of the 13 specific statements about principles. However, responses on behaviors were not necessarily consistent with those on attitudes. 80.3% of respondents reported that they usually or always participated in quality improvement activities and 48.2% reported that they usually or always participated in peer evaluations of colleagues' quality of care. Some 47.8% had encountered incompetent colleagues and 17.7% had encountered significant medical errors caused by colleagues. Among those who had encountered incompetence or significant medical errors, almost two thirds had never reported their concerns to the hospital or other relevant authorities. Half of the physicians did not obtain enough continuing medical education credits. Physicians' professional reported behaviors were influenced by their personal and professional characteristics, professional attitudes, and assessment of hospital internal management constitutions. For example, participation in decision-making had a significant role in professional reported behaviors of protecting patient confidentiality, improving quality of care, and self-regulation, with those sometimes or often participating in decision-making indicating higher levels of reported behaviors than those who seldom participated (odds ratios: 1.84; 4.31, 2.44; 3.31). The results showed Chinese physicians demonstrated positive attitudes to professionalism principles. However, their reported behaviors were at times inconsistent with their attitudes, especially in the areas of competence, quality improvement, and self-regulation. One of effective strategies to facilitate Chinese physicians' professionalism may be to improving hospital management.

Obesity is a risk factor for chronic kidney disease, and its prevalence among the elderly is increasing. We investigated the effects of changes in body fat percentage (BFP) on the longitudinal changes in the estimated glomerular filtration rate (eGFR) in the elderly. This prospective cohort study included 390 participants aged >65 years who underwent bioelectrical impedance analysis at baseline and follow-up as a part of the Korean Longitudinal Study on Health and Aging. After a median follow-up period of 5.3 years, BFP was significantly higher than that at the start point (P<0.05). Participants who had the largest increase in BFP had the highest BMI and waist circumference (WC) (P<0.001). The highest tertile had the highest white blood cell count and erythrocyte sedimentation rate, incidence of rapid progression, and decline in eGFR >25% (P≤0.017, P = 0.025, P = 0.005, respectively). The lowest tertile had the lowest triglyceride and highest high-density lipoprotein levels (P<0.05). The adjusted decline rate in eGFR was correlated with a change in BFP (P = 0.039), but not with that in BMI or WC. The highest tertile had a 4.875-fold increase in the risk for rapid progression to a decline in eGFR (95% CI: 1.366–17.397) and a 4.931-fold decrease in the risk to a decline in eGFR>25% (95% CI: 1.617–15.037), when compared with the lowest tertile. In subgroup analysis, the incidence of renal outcomes was significantly increased according to the increase in BFP in patients with lower eGFR (P≤0.010). A change in BFP may be associated with inflammation and dyslipidemia development, and longitudinal changes in body fat are related to a decrease in eGFR in the elderly.

Purpose -The purpose of this paper is to use systemic thinking to explain and predict the cost of logistics outsourcing, and to devise policies to minimize the cost of risk. Design/methodology/approach -A method of system dynamics is adopted to capture the dynamic interaction of logistics outsourcing systems and to analyze the impact of some factors in the system on policy decisions over a long-term horizon.Findings -This paper illustrates the internal mechanism of the logistics outsourcing cost of risk systems by virtue of system dynamic principles, to develop a system dynamics model, and to give a quite detailed description of how the model could work. Practical implications -The results of the simulation analysis provide useful information for logistics outsourcing risk managers. Originality/value -This paper contributes to the discussion on the use of system dynamics for studying logistics outsourcing cost of risk.